Laserfiche WebLink
San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplement <br /> JOB ADDRESS: 2�. 5�Snufnti, -r,Dlrf!ti ____ PERMIT SR#: obi 3� <br /> +T' <br /> LICENSED CONTRACTORS DECLARATION (LCD} <br /> I hereby affirm that I am licensed under the provisions of Chapter 9(commencing with Section 7000)of Division <br /> 3 of the Business andProfessionsCade and my license is in full force and effect. <br /> License#: %4 �J :�)S ! Expiration Date: ► 31 f 2��� <br /> Date: Contractor: r--Lz W5L-L �1J 04N iJT <br /> Signature• Title: //2J f� tA�i— <br /> V�' <br /> Printed name:62e; <br /> WORKERS' COMPENSATION DECLARATION <br /> I hereby affirm under penalty of perjury one of the following declarations: (CHECK ONE) <br /> _I have and will maintain a certificate of consent to self-insure for workers'compensation, as provided for <br /> by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. <br /> I have and will maintain workers'compensation insurance, as required by Section 3700 of the Labor Code, <br /> for the performance of the work for which this permit is issued. My workers'compensation insurance <br /> carrier and policy numbers a <br /> Carrier: Policy Number:;713 — 0012000 -0-7- <br /> I certify that in the performance of the work for which this permit is issued, I shall not employ any person in <br /> any manner so as to become subject to the workers'compensation laws of California, and agree that if I <br /> should become subject to the workers'compensation provisions of Section 3700 of the Labor Code, I shall <br /> forthwith comply with those provisions. <br /> Expiration Date; / Signature: i <br /> Printed Name: / 1 e-- <br /> WARNING: FAILURE TO SECURE WORKERS'COMPENSATION CO ERAGE IS UNLAWFUL,AND SHALL SUBJECT <br /> AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS <br /> ($100,000,),IN ADDITION TO THE COST OF COMPENSATION,INTEREST,ATTORNEY'S FEES,AND DAMAGES AS <br /> PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br /> AU HO IZATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br /> op <br /> 1, (signature ofC-57 licensed authorized representative), <br /> hereby authorize(print name)[L i— 1�1 r=_�RpQiZc�sJ�I�O+�t•[�w� t N��, <br /> to sign this San Joaquin County Well Permit Application on my behalf. I understand this authorization Is valid for <br /> one(1)year and is limited to the work plan dated on the front page of this application. <br /> B-29-021 MI <br /> Elim 29-02-001 <br /> 1071N <br />